1942290804 NPI number — COLLEEN ODONNELL P.A.

Table of content: COLLEEN ODONNELL P.A. (NPI 1942290804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942290804 NPI number — COLLEEN ODONNELL P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ODONNELL
Provider First Name:
COLLEEN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942290804
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4017 N WOLF CREEK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDEN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84310-9894
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-690-6456
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2132 N 1700 W STE 230
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAYTON
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84041-7060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-773-3900
Provider Business Practice Location Address Fax Number:
801-773-3900
Provider Enumeration Date:
10/24/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  007859-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: 6526009-1206 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02108996 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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